Wednesday, 4 March 2009

I've been really enjoying my time away from work. Taking time to pause tends to make me a bit philosophical and I'm going to write about something that I've been giving quite a lot of thought to.

"How do you cope with stress?"

This was one of the questions I was asked at my interview for medical school when I was seventeen years old and it’s something I’ve been pondering recently.

Without a shadow of a doubt, working as a doctor can be incredibly stressful. There have been times during or after emergencies when I’ve been close to losing it completely but, more insidiously, there’s an undercurrent of stress that all doctors have to cope with. How we cope with this is something that is hardly ever spoken about at work, or even outside work. I think there is something quite fundamentally challenging about the environment we doctors have to work in and I’ll try and explain why.

As individuals, people who apply to medical school are very comfortable and happy with health and healthy people. We see good health as being important and something to strive for. Part of the reason we go to medical school in the first place is because we want to help other people achieve the good health that we see as being so important. It’s not a great leap of logic to assume that someone like Slobodan Milosevic wouldn’t have been interested in applying to medical school. So, it follows that the people who apply to medical school are at ease and are comfortable in environments where people are healthy.

As a doctor, you are put in an environment where people are not healthy. You have to work every day in hospitals and hospitals are full of ill people. In other words, you spend the majority of your time in an environment that is the direct opposite to the one in which you feel most comfortable. At any given time, the sickest people in the whole region are right there in your workplace. You’re in an environment when people are so ill that they die. They die every day. You try and help, you try as hard as you can, but they still die. They still die every day. For a person who is most comfortable among the healthy, this sort of environment automatically causes stress. Sometimes great amounts of stress, sometimes so much stress that the doctor can’t cope and ends up having a breakdown or even committing suicide.

Which brings me back to the point of the article – how do we cope? Why don’t all doctors kill themselves? Why do the majority of my medical colleagues honestly tell me that they “enjoy their job?”

It starts in medical school. During your journey through medical school, you learn a hell of a lot of stuff. Medical students will be able to tell you what the sartorious muscle does, why we always sniff when we cry, how to spot cancerous cell down a microscope, at what gestational age the foetal heart beats for the first time, and so on and so on… but I’m now realising that one of the most important things you learn as an undergraduate is how to cope with the hospital environment. You learn how to cope with disease, how to cope with death and, more fundamentally, how to cope with the stress that disease and death will cause to you. You’re introduced to the hospital in a very measured way and, even though we don’t realise it at that stage, it’s at medical school that we learn our coping mechanisms.

But how we cope is not really tested until we become doctors.

Before I started working, I would try and be conscienscious and I’d spend lots of time in the hospital, but at the back of my mind, I knew that I could leave at any time. If I felt unwell I could leave, if I felt tired I could go home and everything would be just fine without me. The patients didn’t need me, their relatives didn’t need me, the hospital staff didn’t need me and I knew that I wouldn’t really be missed if I wasn’t there.

That all changed on my first shift as a doctor. Suddenly, the responsibility was mine. I inherited 25 patients to look after and I had to cope with the fear, the anxiety, and responsibility of trying as best I could to make them all better and get them home. And try I did, but here’s the thing – the work never ends. One patient gets well enough to leave and within minutes, there’ll be a new patient in the bed that’s just been vacated. A whole new person with a whole new set of problems for me to try and remedy and the whole cycle starts again. And this happens again and again ad infinitum.

What I’m trying to get across is that those coping mechanisms that we develop in med school get tested to destruction when we become doctors. Some people’s coping mechanisms stand up, others’ don’t and people have to try and find new ways of coping. I’ve scratched my head a bit and I’m going to try and write about some of the ways that doctors cope with stress.

Working harder

From what I’ve seen, this is the most common one by far. I’ve already mentioned that your work as a doctor never actually stops. There’s always another patient to clerk, another blood test to do, another X-ray to review, another letter to write, another audit to complete, another relative to talk to, another referral to make, the list goes on and on and on. You really can bury yourself in your work to the point that it seems like nothing else matters.

Dr X will say, “I can’t possibly go home yet, I have another four sets of blood tests to do, and repeat Mr Brown’s ABG and make sure everything is prepared for tomorrow’s consultant ward-round…” However, if you scratch the surface a little, you’ll find that the real reason that Dr X is still at work four hours after her shift finished is that Dr X finds NOT working far more stressful than working. You see, when you’re at work, you don’t have time to feel stressed because there’s so much more stuff to get done. At home on your own though… well that’s another story. So Dr X works harder and harder and harder so she doesn’t have to face up to her own thoughts and stresses.I’m guessing that this sort of thing was more common in the days when junior doctors had to work all day and all night every day and every night, but it’s still very common now in 2009.

Colleagues

Ever wondered why at university medical students seemed to hang out only with other medical students? We just didn’t seem to mix as much with other students did we? It’s partly due to the (relative) intensity of the degree we chose to study, but more importantly it’s that we automatically had a common bond with each other. We had a shared set of experiences that only other medical students could understand, because they were there too. I remember when I was a Fresher and I told a history student that I had to dissect a real, dead person as part of my studies. He was fascinated (and a little grossed out), but he didn’t really understand what it felt like because he wasn’t there. I tried to share with him that I had a nagging feeling that cutting this man’s neck apart was WRONG, WRONG, WRONG because, he was alive once. I tried to tell him that I imagined what he would have been like when he was alive (Jovial? Stupid? Intelligent? Funny? Rich? Poor?) and I had such a massive amount of respect that he’d let me do this to his body after death. But he didn’t get it, he couldn’t get past the part that I “actually cut his neck open – gross!” so I gave up.This clubbing together of medics doesn’t change after we graduate, if anything, it becomes more marked. Most of my good friends are doctors and it really helps having someone to talk to who’s been through the same experiences. Not only that, you also work with much more senior doctors and nurses who’ve been through it all before, you have role models and people you idolise and this all helps you make sense and cope with events going on around you.

Friends and family

From what I’ve seen, having supportive friends and family is probably the thing that keeps most doctors sane. From a personal point of view, I know that being able to let of steam and rant about the system we work in is incredibly cathartic, even if the person I’m ranting at doesn’t really know what the hell I’m going on about. My friends and family have put up with me when work has made me furious, despondent, frightened or just plain depressed. I know I’m really lucky to have such a supportive social network, whether it’s my Dad saying he’s proud of what I’ve done or it’s my sister telling me that I’m “obviously a good doctor” (like she’d know!), it all helps knowing that they’re there.

Religion

“Though I walk through the valley of the shadow of death, I shall fear no evil.” There can be no doubt that having a faith and a strong belief that there is more to the world than the (sometimes truly horrific) things we see before us helps doctors cope with what they have to do.

Sex

If you work in a hospital for any length of time, you’ll become aware of a strong undercurrent of sexuality with the staff. It’s been there at every hospital I’ve worked. Sometimes it’s understated, but often it’s explicit. There’s lots of flirting, lots of “complementing,” and, if you want it, there’s lots of shagging. I doubt many would admit it but often, this is a coping mechanism. After all it’s much easier to motivate yourself to go to work if you know that a certain medical house officer will be there isn’t it? And it’s much easier to get through the day with thoughts of what the said house officer was doing to you last night running through your head…

Alcohol

Everyone I know has done this, myself included. We’ve all come home and said “I’ve had a REALLY REALLY shitty day at work, come on, we’re going out and I am going to get SMASHED. I want to be so off my face that I can’t see…”And we’ve gone out and got totally of our faces.In and of itself, I don’t think that this isn’t really a big problem, but the thing about alcohol is that it can become incredibly destructive. What started out as a big session once in a blue moon after a particularly shitty week turns into going out every weekend and getting blasted. But you’re not doing it because it’s fun, you’re not doing it to have a good time, in fact, you don’t actually enjoy getting drunk at all, you’re just doing it because when you’re drunk, you can forget about the hospital and how being in the hospital makes you feel. Then you find yourself drinking routinely everyday after work, slowly drinking more and more each evening. Then you suddenly find that you can’t get through the day without a drink… At this point your work colleagues start talking about you and how you smell of gin half way through the morning…Alcohol is insidious, I wouldn’t really call it a “coping strategy” but I’d predict that the vast majority of doctors lie somewhere along the scale that starts with “getting drunk to forget once in a blue moon” and ends with “being an alcoholic.”

Drugs

Doctors doing drugs is a huge taboo, but we know it goes on. The reasons are pretty similar to those outlined above for alcohol. Remember that doctors know more about the drugs they are taking than your average man on the street, we have much more access to uncontaminated drugs, we know what their side-effects are and we know how to hide them.

Other activities

One of the thing I’ve noticed in my career so far is that as junior doctors’ working hours have reduced (currently, a junior doc will work an average of between 44 and 60 hrs every week), doctors are taking more opportunity to “get away from it all.” Doctors now have more time to develop hobbies, be that sports, hiking, travelling, music, painting, charity work, it seems to me that the general chit-chat among doctors isn’t as focused on medicine as it used to be and I believe this is the result of more of having a life outside work.

I appreciate that this post has become very long and really, I’m just jotting down my own personal observations and thoughts but, like I said, how we actually cope with what we have to do is not something that gets spoken about very often.

I qualified in '90 when we were still doing long weeks (70-100+hrs a week as a house officer with those great weekend shifts of saturday morning til monday night) and I really identify with the workaholic coping mechanism. During my first couple of years I had so little life outside the hospital (not much time left over after you added in some sleep) and it was such an effort to stagger out of the hospital that I ended up staying to check patient notes etc after the day was finished. I also couldn't cope with the thought that I hadn't done my best for everyone. After getting my MRCOG I realised that I couldn't cope with the stress of being an obstetrician (still lots of night/weekend involvement at a senior level) and having a family and my husband's very busy (and better paid) non-medical career. So I am now an ex-doc!I miss labour ward, but on the whole hospitals can be stressful places and you have to choose how to cope with it at the end of the day. I am now a doctor by proxy through reading blogs. Thanks for blogging!

I think you forgot to mention one of the biggest stressors of life in hospital medicine. The beaurocracy. The endless cycles of form filling, bed managers and other mindless automatrons that add so much friction to even the most simplest of tasks. In some ways, the difficult issues with life and death is a processes which we can all rationalise ("I did my best" etc - and as you say we gradually are exposed to and develop the ability to do this at medical school) but having to constantly leap over the endless and uncessary AND UNJUSTIFIABLE hurdles put in place by administrators and the like is often the real source of drain and misery.

It's Saturday morning and I have to go to work. I have already worked 7.30am-7pm all week and I don't want to work until 9pm this evening. Like you said, it will be non-stop and unless I somehow manage to magically disappear from nurses, I will not manage to get a break.

I hate my job. I spent 6 years of medical school thinking I would be a great doctor and would adore my job. Not. True.

Every night when I come home, I panic that I have forgotten to do something vital for someone, or made a terrible error. The worst thing is, part of that is motivated by the fact that I don't want the patient to become more ill, but a not insignificant element is related to the fact that I don't want to be in trouble with the GMC / my Consultant.

When I come home, I sometimes do something run-of-the-mill fun with my friends (cinema, restaurant etc), but more often than not I have about 3 hours to sit down, eat, watch crap TV and sleep, all on my own.

I'm currently a very junior member of the team, with zero interest in the specialty I work in, and I am counting the days until I escape. But escape into what? I'm not going to become a GP. It's just as stressful in its own way, and it's not just a job to do simple as a 'default' option.

Bleurgh. Don't get me wrong, I might sound like I'm in the depths of despair but I'm not. I sort of enjoy it while I'm there, and there's no job I can imagine I would prefer. It's certainly not dull. But it's so relentless, and near enough every decision I make could have negative consequences.

I tell myself that the more senior I become, the more experienced I am and the more time I spend in a specialty I have actually chosen, the better it will be.

Anyway, It's 7.10ish, and I have to work all weekend, so I must dash. I'm glad I read this, knowing that someone has spotted so many of my traits in other docs, especially the 'work harder' strategy.

Very thought provoking. There are few careers with as much stress as being a doctor...you have peoples lives in your hands in the most literal sense possible; that stress alone is unimaginable to the non-medic like myself!

Your post was really interesting and thought-provoking for me because I've spent a lot of time this weekend thinking about how I cope with stress in my job. I'm a psychiatry F1 and initially found it really stressful being landed in job that I knew very little about with not much senior support (no reg, SHO on leave, consultant based in community majority of the time). I definitely tried a few of those coping strategies Doctoring is stressful and I know that people outside don't realise how different it is to sitting at a desk doing 'normal' jobs. Thanks for the post, it really made me think.

I suppose one thing I feel I need to point out is that a career as a doctor need not necessarily involve long hours and high levels of stress. In many respects the key to managing stress long-term is to find where you really want to be, and stay there.

You can work as a doctor across a range of fields and in numerous different settings. For myself, I have always known that I did not want to work long hours, and did not really enjoy constant and relentless pressure in the way that has been described. I have ended up choosing my career using these as 'must-have' options.

I am a forensic psychiatrist (currently a specialist registrar). I work from 9am-5pm, Monday to Friday. I do on-calls, but these are from home, and on 99% of occasions I do not get called. If I do get called, I usually need only to give advice. Rarely I have to go into the hospital, or a police station to sort out a crisis.

I have only been resident on-call for 18months in my entire career (8 years so far). This is luck to a large extent, but also in part due to making the right choices.

As a consultant I can expect a very similar lifestyle. Admittedly, many people would see my job as highly stressful - I am responsible for supervising the hospital and community treatment of mentally ill people who pose considerable risks, and have committed serious offences including homicide. I give opinions to the Courts on how to deal with such people, and spend time in prisons treating inmates for mental illness.

However, I don't see it that way. I enjoy doing my job, and I have sufficient training now to know that I am competent to do it.

This is how I cope with stress. I think these principles apply to everyone though - identify what you need in terms of lifestyle, as well as specialty. I think it is quite reasonable to prioritise lifestyle, as ultimately it is your life. And once other people's lives become linked with your own (eg getting married, and particularly having children - I have 2 boys and another on the way) it becomes harder and harder to justify career over lifestyle.

Thank you for sharing. I'm a RN and work in a high-volume hospital, and although I get to leave said hospital, and it's patients, each week, I can certainly relate to and understand much of what you wrote. The responsibility healthcare providers have is immense. And more and more, it seems, patients are developing a kind of contempt, as if we don't provide proper treatment or we are not there to help them. There is always some article they read, or something they don't understand though it has been explained a million times. Sometimes it is just a general attitude as if we are the reasons they are in such bad health because we are not able to correct 50+ years of poor lifestyle choices. I've been dating an oncologist for 6 months and in that short time, getting a peek into his life, my struggle with never achieving a lifelong dream of becoming a doctor has turned into a colossal relief that I am not one. Thank you for the work you do, doctor. I wish more people would realize the difficulty of saving yourself while trying to save them.

I stumbled across this post and it really hit a nerve. I'm an F1 and think I have used most of the coping strategies described by you!

So what is it about the job that is so stressful? Knowing that you are chained to the bleep, which can go off when you are eating, sleeping, or going to the toilet. Knowing that the moment you walk onto a ward you will get calls of 'doctor, can you just write up some fluids/analgesia/warfarin/speak to the relatives'. Knowing that when you might get called to see a patient in the night that doesn't sound too bad over the phone, then the sudden feeling of panic as you realise they are seriously sick and you haven't got a fucking clue what to do.

Long hours? Pah- I barely have a life outside work since this year anyway. Being bollocked by your consultant-unpleasant, but you soon learn to shut it out. It's other stuff that takes its toll.

You forget one important defence mechanism-humour. Black, sick, unrepeatable outside the hospital walls...it gets us through the day and makes us feel like somehow, if we share it with someone else, we're not alone.

I want to become a doctor, and i am curious, how in the world did you have an interview for medical school at seventeen? I am still working toward my Bachelors. Also, is it as hard as they say o get in? Were you more in debt that you could afford when you graduated? Did you have any type of life when you were in medical school? Thank you!

Thanks for posting such an awesome blog. Nice to know that I am not all alone! I am starting work next week and believe it or not, I am actually sh***** my pants!! I know this will be the hardest thing I ever do, even harder than taking my medical final exams!!!

Well, the real challenge starts as an F1.

Goodluck to all you guys how are starting this August and please post your experiences!!

hello, I'm a medical student now in my first semester. Having finals now, and i'm feeling stressed because there are loads to study and so little time!

Eventhough I planned my time and I was on schedule, I still feel this stress in me that I cried a few times already. Before this, we had test every week and I was ok with that. I don't know how to cope with this and maybe someone here might be able to help?

I used to face this during my exam when I was in higher secondary school. What can i do?

To the person who is applying to do medicine this year- don't do it to yourself!!! If you want a life and do not want to be jumping through hoops for the rest of your life, constantly worried that you haven't done something or missed something etc. Its a rewarding job but its not worth your life.Quote 'a job is a small corner of your life and everything else makes up the rest' unless your a doctor.....

Rarely do you get to talk about or hear about personal issues that other colleagues go through. Blogs like these really make me feel not alone. Completely underestimated the weight of doing Medicine... don't think I would have appreciated 'doctors' as much if I wasn't do medicine/doctor-ing. All the best.

I work in general dental practice, I've been fascinated reading all the comments. Stress is a huge underestimated factor in my opinion. We all know the physiology of the stress response. But chronic stress as exemplified by the wonderful book by Prof. Robert Sapolsky in 'why zebras don't get ulcers' is a significant factor in both psychological and physical disease processess. I unfortunately spent a night in hospital some 3 months ago following periorbital cellulitis and observed the doctors and medical staff closely I wish you all long and prosperous careers with long healthy lives!:)

I'm currently in my fourth year of being a doctor. I just had a call from a GP about why they can't follow up on their patient because tomorrow is "their day off". Don't tell the hospital registrar about days off and expect sympathy. Idiot.

If you're thinking of becoming a doctor, don't. No lunch breaks or time to go to the bathroom. But worst of all, ungrateful patients and GPs/consultants/administration staff who blackmail you because they are too lazy to do their own work.

I know the previous post was in 2013, but I needed to vent. I can't wait to leave the hospital system and not be dictated by it.

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